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Brain reacting to a meaningful target visual stimuli, as seen using Evoke's tech

The US has seen an increase in conditions that impact brain health; 48% of Veterans returning from combat who seek VA treatment are diagnosed with a mental health problem. The rate of reported sports-related concussions has doubled in the past decade. And diagnoses for neurological disorders such as ADHD and dementia have been steadily increasing.

Though there are cases in which medication is absolutely necessary, there are growing concerns about the rapid rise and abuse of psychotropic prescriptions without a proper evaluation by a mental health professional. Dr. James Thompson of Evoke Neuroscience spoke to Hopes&Fears about how biofeedback training can help rehabilitate the physiological changes resulting from traumatic brain injuries.

A physiological approach

In 2009, Doctors James Thompson and David Hagedorn founded Evoke Neuroscience with exactly this goal in mind. Specializing in traumatic brain injuries caused by sports injury and military trauma respectively, both Thompson and Hagedorn were using electrophysiology as a measurement tool to see how injury was affecting brainwaves and heart rate patterns and figure out how they could recover normal functioning. “A lot of medications deal with symptoms [of traumatic brain injury] but aren’t actually treating the root causes of the symptoms,” Dr. Thompson tells Hopes&Fears. “The anxiety, the depression, the sleep disorders—they’re all a result of physiological changes in your brain.”

Medication can provide supplementation or re-uptake certain chemicals that cause these symptoms, but take away the medication and the chemical processes still haven’t been cured. Instead, Evoke uses brain processing speed measures, cardiac measures and neuropsychological testing to target parts of the brain which aren’t functioning properly, and then uses neurofeedback to train the neurons back to health. “By doing EEG neurofeedback training, you’re teaching the neurons to release chemicals and to communicate in specific patterns. And by reinforcing those patterns, the neurons actually learn to communicate in a process called long term potentiation,” Thompson explains. “The saying is, ‘the neurons that fire together, wire together.’”

James Thompson, Ph.D.,BCN

Co-Founder, Chief Science Officer/Chief Technical Officer

Dr. Thompson specializes in the use of Neurological and Physiological testing and training techniques for assessment and active care in rehabilitating TBI and for performance enhancement. His doctorate studies focused on the assessment of concussions in athletes using EEG, postural assessments and neuropsychological testing.

The problem, Thompson says, is that this information is hard to collect, requiring data collection using multiple measurement systems and hours of cross-specialty analysis. So while neurofeedback and heart rate variability (HRV) training have been shown in a multitude of peer reviewedliterature publications to be effective in remediation the negative effects of central and autonomic nervous system trauma such as concussion and PTSD, the roadblocks in knowledge and access keep physicians from practicing them. What Evoke has developed is a system that puts all of the software, hardware and education in one accessible, easy-to-use place. “We thought, ‘wouldn’t it be cool to get access to this type of information to more practitioners?’” Thompson recalls. “Instead of two hours just to collect the data, our system can do it in just 20 minutes.”

The Evoke team also provides a multifaceted education program with training manuals, bi-monthly live webinars and over 250 research references so that doctors can read the original studies behind specific parts of their tools. "It's like a specified internet," Thompson jokes, "we brought all the information together so they don’t have to go searching for multiple hours."

What is Heart Rate Variability?

HRV is the physiological phenomenon of variation in the time interval between heartbeats. High HRV is associated with heart attack survival, reduced stress, and improved sleep, while low HRV is associated with hypertension, cardiac arrest, depression and anxiety. By breathing at a resonant frequency, which is about six breaths per minute, you can train this reflex and the cardiovascular system to increase heart health and improve resilience to recover from stress and anxiety. Source

How it works

The Evoke system is a portable brain-computer interface that allows physicians to assess the extent and specific locations of brain injury by conducting EEG readings using a special device fondly called the “Michael Phelps” due to its swim cap-like appearance. Heart and breath rate are also measured, giving the physician a full picture of a patient’s central and autonomic nervous systems. With a report in hand, the physician can create a training program that targets those specific brain areas that are not performing optimally to get them to “fire and wire” together. "When the neurons in those regions start firing the way we want them to, the person gets rewarded by an auditory sound or visual cue that basically says, 'good job,'" Thompson explains, "by getting that reward, chemicals are released and the neurons learn to uptake those chemicals, which is reinforced by doing the training over and over again."

Take your typical concussion patient. Traditionally, related symptoms such as chronic headaches and sleep disorders are treated using medication with hopes that patients can cope with the symptoms long enough for the concussion to resolve itself. But with Evoke’s system, a doctor can identify the physiological problems and prescribe treatment that actually resolves the functional damage caused by the concussion. So if the patient is experiencing sudden difficulty with their emotional regulation for instance, a doctor can check for frontal lobe functionality, which deals with emotional regulation, and assess whether it’s functioning optimally. Or if the patient is complaining of headaches, a physician can measure heart rate variability which, when unbalanced, can affect blood flow, thus causing headaches. With this information, a physician can target neurofeedback training to the frontal lobe or set up an HRV program to re-regulate blood flow. Combined with proper medications and supplements, the Evoke system rounds off a holistic approach toward rehabilitation.

Typically patients will do neurofeedback training an average of three days a week, in about twenty to forty sessions running about 30 minutes each. “Your brain is plastic, meaning it can change,” Thompson explains, “by training it and exercising your brain it literally changes to meet the criteria you set for it. So in training, your brain is learning the patterns that are more normal.” Patients are also provided with a wristband and training app that goes home with them so they can train between scheduled doctor’s visits, much like the prescription model that practitioners are already used to.

A screenshot of Mindja, a biofeedback app currently being developed by Evoke. By controlling heart rate and breathing patterns while playing this Mario-like game, you learn how to maintain a reduced stress level and high HRV even when under performance pressure.

Tried, tested and true

The spectrum of patients who can benefit from biofeedback training is remarkably broad, from young people with ADHD, to athletes with sports injuries, to professionals working in high-stress environments suffering from crippling anxiety and sleep disorders as a result. Physicians using Evoke’s technology also see a lot of Veterans suffering from psychophysiological disorders resulting from PTSD, as well as older people experiencing mild cognitive impairment that comes naturally with age or who use HRV rehabilitation after a cardiac event. “There’s a lot of researchdemonstrating a significant reduction in the likelihood of a second heart attack if you do HRV training after your first heart attack,” Thompson points out.

Though Evoke is in no way proposing that biofeedback trainings can completely replace medication, there is no doubt that the system is an effective rehabilitation tool. “In terms of whether the technology we’re developing is going to be helpful, we know that it will. We didn’t invent HRV training or brainwave analysis or neurofeedback,” notes Thompson. “Those all existed already; brainwave patterns were discovered in 1924 by Hans Berger. Neurofeedback and the ability to train specific patterns and change brain functioning has been around since the 1960s. We didn’t invent anything. All we did was make it accessible, easy and understandable.”

How cats

and NASA started neurofeedback training

In the late 1960s, NASA noticed that their engineers and astronauts were developing seizure syndromes as a result of long-term exposure to rocket fuel, so they hired Dr. Barry Sterman, a Neurobiologist to try to figure out the root cause. When Sterman used cats to replicate the environment experienced by NASA employees, he noticed that half of the cats were getting seizures while the other half weren’t. It turns out the cats not getting seizures were part of a previous study on neurofeedback training; these cats had changed their brain patterns to reduce activity along the motor strip, allowing them to prevent seizures. Source